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HomeMy Public PortalAbout682688 Page 1 of 29 rev 11-21-13 THE METROPOLITAN ST. LOUIS SEWER DISTRICT 2350 Market Street St. Louis, MO 63103 Attn: Purchasing Department Amanda Cooper (314)768-6329 Or Lisa Treat (314)768-6269 2013 - 2014 EXPERIENCE QUESTIONNAIRE (USED IN PRE-QUALIFYING BIDDERS ON CONSTRUCTION WORK) ___________________________________________________________ SUBMITTED BY (COMPANY) ___________________________________________________________ ADDRESS ___________________________________________________________ CITY, STATE, ZIP CODE ___________________________________________________________ DATE ___________________________________________________________ CONTACT NAME (FOR QUESTIONS) - TELEPHONE & FAX TAX ID NUMBER _____________________________________________________________ E-MAIL ADDRESS Page 2 of 29 rev 11-21-13 PREQUALIFICATION CHECK LIST Below is a checklist of required documentation  Signed application and boxes checked indicating type of work requested – (Page 9).  Signed Conflict of Interest Statement (Page 5).  Bonding capacity indicated (Page 10)  Equipment Sheet is complete (Page 24)  Affidavit is complete with Notary Seal (Page 25, 26, or 27), whichever is applicable.  Attach Certificate from the Secretary of State showing company is authorized to transact business in the State of Missouri.  Attach ACCORD Certificate of Insurance with MSD as certificate holder.  Attach drain layers license for City of St. Louis and/or St. Louis County (required for Sewer Construction and Deep Sewer Construction categories)  Demolition work for MSD within the City of St. Louis – attach certification for specific classification. o Class I – no building size restrictions. o Class II Limited to buildings under 3 stories/50 feet high/50,000 square feet area/200,000 cubic feet volume. o Buildings under 1 ½ stories/10,000 cubic feet volume, with no basement, require no demolition license. o St. Louis County does not require license. Page 3 of 29 rev 11-21-13 RULES AND REGULATIONS FOR PREQUALIFICATION OF CONTRACTORS ON WORK LET BY CONTRACT WITH THE METROPOLITAN ST. LOUIS SEWER DISTRICT 1. An applicant for pre-qualification must furnish, under oath, detailed information with respect to its equipment, past record, personnel, and experience, together with other information as is called for in this Experience Questionnaire. 2. For a contractor to bid on a project they must be prequalified prior to the bid being opened. 3. Any combination of qualified or unqualified contractors bidding jointly becomes a new contracting firm and it must be pre-qualified in accordance with these rules. All applications shall be in writing and signed by the principal parties in the joint venture. 4. An Experience Questionnaire on forms furnished by the Purchasing Manager must be filed BY October 1st of each year in order to renew pre-qualification. This form must be completed in detail. The District may require any additional information deem ed necessary for pre-qualification. Companies pre-qualified within 3 months prior to this date will not need to submit a renewal application until O ctober 1st of the following year. 5. No bidder will be pre-qualified unless its Experience Questionnaire indicates that it has the experience, organization, and equipment, sufficient in the judgment of the District, that it can satisfactorily execute its contracts and meet its obligations therein incurred. 6. The Financial Statement of the controlling individual or corporate owner of the business shall be submitted; if in the opinion of the District it is required. 7. If any significant change occurs in the in formation included on the contractors’ pre- qualification form, notice shall be given to the District immediately. 8. All Corporations must furnish a certificate from the Secretary of State showing that it is authorized to transact business in the State of Missouri 9. A copy of your firm's Certificate of Insurance meeting the Districts coverages is required. 10. A copy of the applicable drain layers license from the City and/or County of St. Louis is required for Sewer Construction or Deep Sewer Construction. 11. Demolition work for MSD within the City of St. Louis – attach certification for specific classification. o Class I – no building size restrictions. o Class II Limited to buildings under 3 stories/50 feet high/50,000 square feet area/200,000 cubic feet volume. o Buildings under 1 ½ stories/10,000 cubic feet volume, with no basement, require no demolition license. o St. Louis County does not require a license. NOTE: It is important that the "work experience" section be completed and that it contains projects of the type for which pre-qualification is being requested. Pre-qualification will not be granted for types of work that you subcontract to others. Page 4 of 29 rev 11-21-13 IMPORTANT INFORMATION FOR PROSPECTIVE BIDDERS 1. CONTRACT DOCUMENTS Contract documents include, but may not be limited to, the advertisement, Instructions to Bidders, Proposal, General Specifications, Detailed Specifications, Agreement, Bond Form, and Plans. The documents are available on and after the day advertisement is published and will be available via MSD’s website at www.stlmsd.com. Look for a link to “ELECTRONIC PLANROOM”. Plans and specifications are also available for viewing or purchase at Cross Rhodes Reprographics located at 1710 Macklind Avenue, St Louis MO 63110. 2. DEPOSIT FOR DOCUMENTS The charge for contract documents is not refundable. 3. PREQUALIFICATION Bidders not already pre-qualified may make application for pre-qualification to the Purchasing Manager, The Metropolitan St. Louis Sewer District, 2350 Market Street, St. Louis, MO 63103. A contractor must be pre-qualified prior to bids being opened. 4. SPECIAL PROVISIONS Any special provisions or requirements concerning the work on any particular contract will be noted in the contract documents or on the Plans. 5. MINIMUM WAGE AND EMPLOYMENT DISCRIMINATION The minimum wage to be paid to all labor will be shown in the contract documents where applicable. Prevailing rates of pay shall be paid to skilled and unskilled labor, and there shall be no discrimination in the selection or employment of labor on account of race, creed, or color. 6. PROPOSAL DEPOSIT The Proposal shall be accompanied by a certified check or cashier's check drawn on a bank or trust company located in either St. Louis City or County or by a bid bond issued by a surety company satisfactory to the District and which is authorized to transact business in Missouri. 7. RIGHT TO REJECT The Metropolitan St. Louis Sewer District reserves the right to reject any and all bids and to waive technicalities. Page 5 of 29 rev 11-21-13 VENDOR’S CONFLICT OF INTEREST QUESTIONNAIRE 1. Name the individual or company requesting to do business with The Metropolitan St. Louis Sewer District (MSD). 2. In the past two (2) years has the individual or company name in 1. above (or any principal of such company, i.e. partner, officer, director, etc.) contributed cash or gifts in excess of $200.00 in value in the aggregate in any calendar year to any of the individuals or organizations listed on Attachment A hereto? Yes No If yes, describe in detail (date/amount/description). 1. In the past two (2) years, has the individual or company named in 1. above done business with any person listed in Attachment and/or their respective companies. Yes No If yes, describe in detail (date/amount/description). 4. The undersigned certifies that the above information is true and correct to the best of his or her knowledge and belief. Dated this day of _________________. 20 _ Printed Name: _____ Title: _____ Company Name: _____ Signature: _____ Page 6 of 29 rev 11-21-13 ATTACHMENT A Updated January 1, 2013 Attachment "A" contains a list of the MSD Trustees and their re spective employer, MSD officers and Directors, and the organizations which each are individually associated with, as applicable. MSD BOARD OF TRUSTEES Trustee/Director Name of Firm, Organization or Company Affiliation Robert T. Berry American Public Works Association Member American Society of Civil Engineers Member Circle Club of St. Louis Member Engineer’s Club of St. Louis Member Engineers Without Borders Member Huntbridge Forest Subdivision Secretary Manchester UMC Board of Trustees Member Masonic Lodge of Missouri Member Missouri Athletic Club Member Missouri Botanical Garden Member Missouri Society of Professional Engineers Member Missouri University of Science & Technology Adjunct Professor Missouri University of Science & Technology Academy of Civil Engineers Member Missouri University of Science & Technology Academy of Miner Athletics Member Missouri University of Science & Technology Alumni Association Member, Executive Committee Moolah Shrine Temple Member Professional Training for Engineers, LLC President Racquet Ruckus Foundation Chairman Reserve Officers Association Member Scottish Rite Bodies Member U.S. Army Reserves, Retired Retired Officer Water Environment Federation Member James H. Buford African American Jewish Task Force Member Chancellors Council Advocacy Committee - University Missouri-St. Louis Board Member Clear Channel Advisory Board Board Member Commission on Human Rights Board Member Confluence Academy Board and Grand Center Arts Academy Board Member Fair St. Louis Board Member Father Support Center Board Member Fontbonne Council of Regents Member Grand Center Arts District Past Chair and Member Greater St. Louis Area Council, Boy Scouts of America Board Member Heat Up/Cool Down St. Louis Vice Chair Immigration & Innovation Steering Committee Member Jobs For America’s Graduates (JAG) Board Member Mercantile Library Board of Direction Member Midwest Health Initiative Board Board Member Missouri State University Foundation Board Member Norwood Hills Country Club Scholarship Committee Member Rebuilding Together St. Louis Board Member STL 250 Board Board Member St. Louis Artist's Guild Member Page 7 of 29 rev 11-21-13 MSD BOARD OF TRUSTEES Trustee/Director Name of Firm, Organization or Company Affiliation James H. Buford St. Louis Black Repertory Theatre Board Member (cont'd.) St. Louis Black Leadership Roundtable Board Member St. Louis ConnectCare Chairman St. Louis Gateway Classic Sports Foundation Member St. Louis Initiative to Reduce Violence (SIRV) Vice Chair St. Louis Regional Health Commission Board Member St. Louis Science Center Board of Trustees Trustee St. Louis Zoo Board Member The MUNY Board Member The National Conference for Community & Justice Regional Advisory Board Board Member US Bank Board Member Workforce Investment Board of St. Louis County Board Member John H. Goffstein Bartley Goffstein, LLC Member Missouri Bar Association Member St. Louis County Bar Association Member, Past President St. Louis Metropolitan Bar Association Member, former Committee Chair Temple Emanuel Member Eddie Ross, Jr. None Brian Hoelscher American Public Works Association Member American Society of Civil Engineers Member Engineers Club of St. Louis Member Missouri Water Environment Association Member Water Environment Federation Member Annette K. Mandell Central West End Planning & Development Committee Member Missouri Bar Association Member USO Missouri Volunteer West Point Parents Club Member Barbara Mohn Water Wastewater CIO Forum Member Susan M. Myers Association of Corporate Counsel Member Bar Association of Metropolitan St. Louis Member Missouri Bar Association Member Brenda A. Schaefer Association of Financial Professionals Member St. Louis Treasury Management Association Member Government Finance Officers Association Member Betsy Schubert Institute for Supply Management Member Jonathon Sprague American Public Works Association (APWA) Member American Water Works Association (AWWA) Member Engineers Club of St. Louis Member Missouri Water Environment Member National Association of Clean Water Agencies (NACWA) Member Water Environment Federation Member Page 8 of 29 rev 11-21-13 MSD BOARD OF TRUSTEES Trustee/Director Name of Firm, Organization or Company Affiliation Vicki Taylor-Edwards AAIM Management Association Member Certified Employee Benefits Association Member Compensation Benefits Network Member Human Resources Management Association Member International Public Management Association Member Michael E. Yates North County Labor Legislative Club Executive Board Member St. Louis Labor Council Delegate Jan Zimmerman American Water Works Association Member Government Finance Officers Association Member National Association of Female Executives Member National Association of Professional Women Member Women in Public Finance Member Page 9 of 29 rev 11-21-13 APPLICATION TO THE METROPOLITAN ST. LOUIS SEWER DISTRICT FOR CERTIFICATE OF QUALIFICATION TO BID The undersigned hereby applies to the Executive Director of the Metropolitan St. Louis Sewer District for a Certificate of Qualification to bid the followin g types of work: (Check each type of work for which qualification is requested) ________ Sewer Construction (Drain layers license required for City or County) Section V. A., Page 12 ________ Deep Sewer Construction (Drain layers license required for City or County) Section V. B., Page 13 ________ Building Construction Section V. C., Page 14 ________ Natural Channel Restoration and Bio-Retention Section V. D., Page 15 ________ Pipe and Manhole Rehabilitation Section V. E., Page 16 Cured-In-Place Pipe (CIPP) Section V. F, Page 17 & 18 Cured-In-Place Lateral Liner (CIPL) Section V. G, Page 19 & 20 ________ Concrete Channels, Walls and Structures Section V. H., Page 21 ________ Mechanical/Electrical/Plumbing Section V. I., Page 22 ________ Tunneling/Trenchless Section V. J., Page 23 ________ Demolition Section V. K., Page 24 – Refer to page 24 for explanation of Class I & II St. Louis County Demolition St. Louis City – Class I and II St. Louis City – Class II only Note: Sewer Construction shall consist of sewer projects requiring excavation of approximately 20 feet or less in depth and which do not require significant involvement with urban type features such as utilities, structures, urban landscape, other features of an urban nature, or sig nificant amounts of classified excavation. Deep Sewer Construction shall consist of sewer projects requiring excavation of greater than approximately 20 feet in depth and/or that requires significant involvement with trench bracing or urban type features, or significant amounts of classified excavation. The District shall be the sole judge as to the type of construction each project falls under. TYPE OF ORGANIZATION (Check Applicable Category) ______ Corporation ______ Partnership ______ Sole Proprietorship ______ Joint Venture _________________________________ (Firm Name) _________________________________ (Firm Address) _____________________________________________________________________ (Firm City, State, Zip Code) By ___________________________________ Title _________________________ _________________________________(Signature) Page 10 of 29 rev 11-21-13 THE SIGNATORY OF THIS QUESTIONNAIRE GUARANTEES THE TRUTH AND ACCURACY OF ALL STATEMENTS AND OF ALL ANSWERS TO INTERROGATORIES HEREINAFTER MADE Please list any previous experience or projects your company has completed for each category you are requesting approval for, and any references you can provide. Name of Contractor _____________________________________________________ Principal Address _______________________________________________________ ( ) A corporation ( ) A general co-partnership ( ) A limited co-partnership ( ) An individual ( ) Joint Venture ( ) MW BE (Minority or Woman Business Enterprise) If MW BE, what is the name of the agency/organization that issued the certification document. _______________________________________________________________ Please attach a copy of your certification document to this application. Incorporated or organized: Date _______________________ State ______________________________________ Radius of operations: ______________________________________________________ Type of work done: ______________________________________________________ Work usually sublet: Name of Bonding Company _______________________________________________ Total Bonding Capacity of Firm $__________________________________________ I. How many years have you operated under the above name: (a) As general contractor _____________________________________________ (b) As subcontractor ______________________________________________ II. List other names under which you have operated: Name of company _____________________________________________ Type of work done ______________________________________________ Operated during period ______________________________________________ Name of company ______________________________________________ Type of work done ______________________________________________ Operated during period _____________________________________________ Page 11 of 29 rev 11-21-13 III. List of all partners or officers: (Note: if partnership limited, explain and please list full 100% ownership) Name and title _________________________________________________ Address, City and State ____________________________________________ Fractional interest in firm or number of shares owned ______________________ Name and title ____________________________________________________ Address, City and State ____________________________________________ Fractional interest in firm or number of shares owned ______________________ Name and title ___________________________________________________ Address, City and State ____________________________________________ Fractional interest in firm or number of shares owned ______________________ IV. What is the construction experience of the principal individuals of your organization? (This includes the job superintendent). An individual’s name Present position or office Years of construction experience Magnitude and type of work An individual’s name Present position or office Years of construction experience Magnitude and type of work An individual’s name Present position or office Years of construction experience Magnitude and type of work SECTION V. A. Sewer Construction Page 12 rev 11/21/13 V. List all experience for the past five years in the following categories for which you want to qualify. SECTION A. - Sewer Construction (See definition on page 9) (Includes storm sewer, sanitary sewers, and small pump stations) 1. Contract Amount __________________ When Completed __________________ Type of Project ______________________________________________________ Pipe size and length laid ______________________________________________ Location of Project Name, Address & Phone Number of Owner _________________________________________________ 2. Contract Amount _________________ When Completed __________________ Type of Project ______________________________________________________ Pipe size and length laid ______________________________________________ Location of Project ____________________________________________________ Name, Address & Phone Number of Owner ________________________________________________ 3. Contract Amount __________________ When Completed __________________ Type of Project ______________________________________________________ Pipe size and length laid ______________________________________________ Location of Project____________________________________________________ Name, Address & Phone Number of Owner _________________________________________________ 4. Contract Amount _________________ When Completed ___________________ Type of Project_______________________________________________________ Pipe size and length laid ______________________________________________ Location of Project ____________________________________________________ Name, Address & Phone Number of Owner _________________________________________________ SECTION V. B. Deep Sewer Construction Page 13 rev 11/21/13 List all experience for the past five years in the following categories for which you want to qualify. SECTION B. - Deep Sewer Construction (See definition Page 9) (Includes sanitary sewer, storm sewer, and small pump stations) 1. Contract Amount ____________________ When Completed____________________ Type of Project ______________________________________________________ Pipe size, average depth and length laid _________________________________ Location of Project ___________________________________________________ Name, Address & Phone Number of Owner _________________________________________________ 2. Contract Amount ____________________ When Completed________________ Type of Project _______________________________________________________ Pipe size, average depth and length laid Location of Project ____________________________________________________ Name, Address & Phone Number of Owner _________________________________________________ 3. Contract Amount _______________ When Completed Type of Project ______________________________________________________ Pipe size, average depth and length laid Location of Project ___________________________________________________ Name, Address & Phone Number of Owner _________________________________________________ 4. Contract Amount ____________________ When Completed________________ Type of Project ______________________________________________________ Pipe size, average depth and length laid Location of Project ____________________________________________________ Name, Address & Phone Number of Owner _________________________________________________ SECTION V. C. Building Construction Page 14 rev 11/21/13 List all experience for the past five years in the following categories for which you want to qualify. SECTION C - Building Construction (Includes large pump stations, treatment plants, and operational facilities) 1. Contract Amount ___________________ When Completed _______________ Type of Project ___________________________________________________ Location of Project ___________________________________________________ Name, Address & Phone Number of Owner ____________________________________________________ 2. Contract Amount __________________ When Completed ___________________ Type of Project ___________________________________________________ Location of Project ___________________________________________________ Name, Address & Phone Number of Owner ____________________________________________________ 3. Contract Amount __________________ When Completed __________________ Type of Project ___________________________________________________ Location of Project ___________________________________________________ Name, Address & Phone Number of Owner ____________________________________________________ 4. Contract Amount __________________ When Completed ___________________ Type of Project ___________________________________________________ Location of Project ___________________________________________________ Name, Address & Phone Number of Owner ___________________________________________________ 5. Contract Amount __________________ When Completed ___________________ Type of Project ___________________________________________________ Location of Project ___________________________________________________ Name, Address & Phone Number of Owner ____________________________________________________ SECTION V.D. Natural Channel Restoration And Bio-Retention Page 15 rev 11/21/13 List all experience for the past five years in the following categories for which you want to qualify. SECTION D. Natural Channel Restoration and Bio-Retention (Includes hard-armoring, permanent BMP’s and landscaping.) 1. Contract Amount _________________ When Completed Type of Project ______________________________________________________ Location of Project ___________________________________________________ Name, Address & Phone Number of Owner ___________________________________________________ 2. Contract Amount ____________________ When Completed _________________ Type of Project ______________________________________________________ Location of Project ___________________________________________________ Name, Address & Phone Number of Owner ___________________________________________________ 3. Contract Amount ____________________ When Completed _________________ Type of Project ____________________________________________________ Location of Project ___________________________________________________ Name, Address & Phone Number of Owner 4. Contract Amount ____________________ When Completed _________________ Type of Project ___________________________________________________ Location of Project ___________________________________________________ Name, Address & Phone Number of Owner ___________________________________________________ 5. Contract Amount __________________ When Completed ___________________ Type of Project ______________________________________________________ Location of Project __________________________________________________ Name, Address & Phone Number of Owner __________________________________________________ SECTION V. E. Pipe and Manhole Rehabilitation Page 16 rev 11/21/13 List all experience for the past five years in the following categories for which you want to qualify. SECTION E. - Pipe and Manhole Rehabilitation (Give pipe sizes) (Includes point repair, pipe bursting, slip lining, etc.) 1. Contract Amount ________________ When Completed Type of Project __________________________________________________ Location of Project ___________________________________________________ Name, Address & Phone Number of Owner ___________________________________________________ 2. Contract Amount _________________ When Completed ____________________ Type of Project _______________________________________________________ Location of Project ____________________________________________________ Name, Address & Phone Number of Owner ____________________________________________________ 3. Contract Amount ____________________ When Completed _________________ Type of Project ____________________________________________________ Location of Project ____________________________________________________ Name, Address & Phone Number of Owner 4. Contract Amount ____________________ When Completed _________________ Type of Project ____________________________________________________ Location of Project ____________________________________________________ Name, Address & Phone Number of Owner ____________________________________________________ 5. Contract Amount ____________________ When Completed _________________ Type of Project ____________________________________________________ Location of Project ____________________________________________________ Name, Address & Phone Number of Owner ____________________________________________________ SECTION V. F. Cured-in-Place Pipe Page 17 rev 11/21/13 List all experience for the past five years in the following categories for which you want to qualify. SECTION F. – Cured-in-Place Pipe (CIPP) Statement of Qualifications for Cured-in-Place Pipe 1. Project Name: _______________________________________________________ Contract Amount ________________ When Completed Manufacturer of CIPP product ___________ Trade Name of CIPP product ________ Component materials of CIPP (i.e. non-woven polyester felt tube and epoxy vinyl ester resin) _________________________________________________________ Installation Method: Invert: _____ Pull-In: _____ Installed Pipe Length: _____ Pipe Sizes: _____ Pipe Type: Gravity ____ Pressure _______ Project Owner: ______________________________________________________ Contact Name: ___________________________Contact No.:_________________ Relevant ASTM Specification: ASTM F-1216____ ASTM F-1743 ____ Other (please specify) ___________ Lowest 3rd Party D790 Testing Results on Project: Flexural Strength _____________ Flexural Modulus _________________ Tensile Strength _____________ (only applicable for pressure pipe) 2. Project Name: __________________________________________________ Contract Amount ________________ When Completed Manufacturer of CIPP product ___________ Trade Name of CIPP product ________ Component materials of CIPP (i.e. non-woven polyester felt tube and epoxy vinyl ester resin) _________________________________________________________ Installation Method: Invert: _____ Pull-In: _____ Length of Pipe Installed: _______ Pipe Size: _____________ Pipe Type: Gravity _______ Pressure _______ Project Owner: ______________________________________________________ Contact Name: ___________________________Contact No.:_________________ Relevant ASTM Specification: ASTM F-1216____ ASTM F-1743 ____ Other (please specify) ___________ Lowest 3rd Party D790 Testing Results on Project: Flexural Strength _____________ Flexural Modulus _________________ Tensile Strength _____________ (only applicable for pressure pipe) SECTION V. F. Cured-in-Place Pipe Page 18 rev 11/21/13 SECTION F. – Cured-in-Place Pipe (CIPP) Statement of Qualifications for Cured-in-Place Pipe 3. Project Name: __________________________________________________ Contract Amount ________________ When Completed Manufacturer of CIPP product ___________ Trade Name of CIPP product ________ Component materials of CIPP (i.e. non-woven polyester felt tube and epoxy vinyl ester resin) _________________________________________________________ Installation Method: Invert: _____ Pull-In: _____ Length of Pipe Installed: _______ Pipe Size: _____________ Pipe Type: Gravity _______ Pressure _______ Project Owner: ______________________________________________________ Contact Name: ___________________________Contact No.:_________________ Relevant ASTM Specification: ASTM F-1216____ ASTM F-1743 ____ Other (please specify) ___________ Lowest 3rd Party D790 Testing Results on Project: Flexural Strength _____________ Flexural Modulus _________________ Tensile Strength _____________ (only applicable for pressure pipe) 4. Project Name: __________________________________________________ Contract Amount ________________ When Completed Manufacturer of CIPP product ___________ Trade Name of CIPP product ________ Component materials of CIPP (i.e. non-woven polyester felt tube and epoxy vinyl ester resin) _________________________________________________________ Installation Method: Invert: _____ Pull-In: _____ Length of Pipe Installed: _______ Pipe Size: _____________ Pipe Type: Gravity _______ Pressure _______ Project Owner: ______________________________________________________ Contact Name: ___________________________Contact No.:_________________ Relevant ASTM Specification: ASTM F-1216____ ASTM F-1743 ____ Other (please specify) ___________ Lowest 3rd Party D790 Testing Results on Project: Flexural Strength _____________ Flexural Modulus _________________ Tensile Strength _____________ (only applicable for pressure pipe) SECTION V. G. Cured-in-Place Lateral Liner Page 19 rev 11/21/13 List all experience for the past five years in the following categories for which you want to qualify. SECTION G. – Cured in Place Lateral Lining (CIPL) Statement of Qualifications for cured-in-place lateral lining (includes cured-in-place lateral connection repairs). 1. Project Name: _______________________________________________________ Contract Amount ________________ When Completed Manufacturer of CIPL product ___________ Trade Name of CIPL product ________ Component materials of CIPL (i.e. non-woven polyester felt tube and epoxy vinyl ester resin) _________________________________________________________ No. of Laterals Lined: ________ Total Length of Laterals Lined: __________ Manufacturer of Water Tight Seal (waterstop): ______________________________ Manufacturer of Lateral Connection Repair (LCR): __________________________ (Attach written documentation from manufacturer certifying that contractor is an approved installer of their product). No. of LCR’s Installed: __________ Project Owner: ______________________________________________________ Contact Name: ___________________________Contact No.:_________________ Relevant ASTM Specification: Lowest Value of 3rd Party D790 Testing Results on Project: Flexural Strength ____________ Flexural Modulus __________________ 2. Project Name: _______________________________________________________ Contract Amount ________________ When Completed Manufacturer of CIPL product ___________ Trade Name of CIPL product ________ Component materials of CIPL (i.e. non-woven polyester felt tube and epoxy vinyl ester resin) _________________________________________________________ No. of Laterals Lined: ________ Total Length of Laterals Lined: __________ Manufacturer of Water Tight Seal (waterstop): ______________________________ Manufacturer of Lateral Connection Repair (LCR): __________________________ (Attach written documentation from manufacturer certifying that contractor is an approved installer of their product). No. of LCR’s Installed: __________ Project Owner: ______________________________________________________ Contact Name: ___________________________Contact No.:_________________ Relevant ASTM Specification: Lowest Value of 3rd Party D790 Testing Results on Project: Flexural Strength ____________ Flexural Modulus __________________ SECTION V. G. Cured-in-Place Lateral Liner Page 20 rev 11/21/13 SECTION G. – Cured in Place Lateral Lining (CIPL) Statement of Qualifications for cured-in-place lateral lining (includes cured-in-place lateral connection repairs). 3. Project Name: _______________________________________________________ Contract Amount ________________ When Completed Manufacturer of CIPL product ___________ Trade Name of CIPL product ________ Component materials of CIPL (i.e. non-woven polyester felt tube and epoxy vinyl ester resin) _________________________________________________________ No. of Laterals Lined: ________ Total Length of Laterals Lined: __________ Manufacturer of Water Tight Seal (waterstop): ______________________________ Manufacturer of Lateral Connection Repair (LCR): __________________________ (Attach written documentation from manufacturer certifying that contractor is an approved installer of their product). No. of LCR’s Installed: __________ Project Owner: ______________________________________________________ Contact Name: ___________________________Contact No.:_________________ Relevant ASTM Specification: Lowest Value of 3rd Party D790 Testing Results on Project: Flexural Strength ____________ Flexural Modulus __________________ 4. Project Name: _______________________________________________________ Contract Amount ________________ When Completed Manufacturer of CIPL product ___________ Trade Name of CIPL product ________ Component materials of CIPL (i.e. non-woven polyester felt tube and epoxy vinyl ester resin) _________________________________________________________ No. of Laterals Lined: ________ Total Length of Laterals Lined: __________ Manufacturer of Water Tight Seal (waterstop): ______________________________ Manufacturer of Lateral Connection Repair (LCR): __________________________ (Attach written documentation from manufacturer certifying that contractor is an approved installer of their product). No. of LCR’s Installed: __________ Project Owner: ______________________________________________________ Contact Name: ___________________________Contact No.:_________________ Relevant ASTM Specification: Lowest Value of 3rd Party D790 Testing Results on Project: Flexural Strength ____________ Flexural Modulus __________________ SECTION V.H. - Concrete Channels, Walls, & Structures Page 21 rev 11/21/13 List all experience for the past five years in the following categories for which you want to qualify. SECTION H. - Concrete Channels, Walls & Structures 1. Contract Amount ______________ When Completed ________________________ Type of Project _______________________________________________________ Location of Project ________________________________________________ Name, Address & Phone Number of Owner _____________________________________________________ 2. Contract Amount ________________ When Completed ________________________ Type of Project _______________________________________________________ Location of Project _________________________________________________ Name, Address & Phone Number of Owner _____________________________________________________ 3. Contract Amount ________________ When Completed ________________________ Type of Project _______________________________________________________ Location of Project _________________________________________________ Name, Address & Phone Number of Owner _____________________________________________________ 4. Contract Amount ________________ When Completed ________________________ Type of Project _______________________________________________________ Location of Project _________________________________________________ Name, Address & Phone Number of Owner _____________________________________________________ 5. Contract Amount ___________________ When Completed _____________________ Type of Project _____________________________________________________ Location of Project _________________________________________________ Name, Address & Phone Number of Owner _________________________________________________ SECTION V.I. Mechanical/Electrical/Plumbing Page 22 rev 11/21/13 List all experience for the past five years in the following categories for which you want to qualify. SECTION I. - Mechanical/Electrical/Plumbing 1. Contract Amount ______________ When Completed ________________________ Type of Project _______________________________________________________ Location of Project ________________________________________________ Name, Address & Phone Number of Owner _____________________________________________________ 2. Contract Amount ________________ When Completed ________________________ Type of Project _______________________________________________________ Location of Project _________________________________________________ Name, Address & Phone Number of Owner _____________________________________________________ 3. Contract Amount ________________ When Completed ________________________ Type of Project _______________________________________________________ Location of Project _________________________________________________ Name, Address & Phone Number of Owner _____________________________________________________ 4. Contract Amount ________________ When Completed ________________________ Type of Project _______________________________________________________ Location of Project _________________________________________________ Name, Address & Phone Number of Owner _____________________________________________________ 5. Contract Amount ___________________ When Completed _____________________ Type of Project _____________________________________________________ Location of Project _________________________________________________ Name, Address & Phone Number of Owner _________________________________________________ SECTION V. J. – Tunneling/Trenchless Page 23 rev 11/21/13 List all experience for the past five years in the following categories for which you want to qualify. SECTION J. – Tunneling/Trenchless 1. Contract Amount ______________ When Completed ________________________ Type of Project _______________________________________________________ Location of Project ________________________________________________ Name, Address & Phone Number of Owner _____________________________________________________ 2. Contract Amount ________________ When Completed ________________________ Type of Project _______________________________________________________ Location of Project _________________________________________________ Name, Address & Phone Number of Owner _____________________________________________________ 3. Contract Amount ________________ When Completed ________________________ Type of Project _______________________________________________________ Location of Project _________________________________________________ Name, Address & Phone Number of Owner _____________________________________________________ 4. Contract Amount ________________ When Completed ________________________ Type of Project _______________________________________________________ Location of Project _________________________________________________ Name, Address & Phone Number of Owner _____________________________________________________ 5. Contract Amount ___________________ When Completed _____________________ Type of Project _____________________________________________________ Location of Project _________________________________________________ Name, Address & Phone Number of Owner _________________________________________________ SECTION V K. Demolition Page 24 rev 11/21/13 List all experience for the past five years in the following categories for which you want to qualify. SECTION K. – Demolition Demolition work for MSD within the City of St. Louis –attach certification for specific classification. Class I–no building size restrictions. .Class II -limited to buildings under 3 stories/50 feet high/50,000 square feet area/200,000 cubic feet volume. .Buildings under 1 ½ stories/10,000 cubic feet volume, with no basement, require no demolition license. St. Louis County – does not require license. 1. Contract Amount ______________ When Completed ________________________ Type of Project _______________________________________________________ Location of Project ________________________________________________ Name, Address & Phone Number of Owner _____________________________________________________ 2. Contract Amount ________________ When Completed ________________________ Type of Project _______________________________________________________ Location of Project _________________________________________________ Name, Address & Phone Number of Owner _____________________________________________________ 3. Contract Amount ________________ When Completed ________________________ Type of Project _______________________________________________________ Location of Project _________________________________________________ Name, Address & Phone Number of Owner _____________________________________________________ 4. Contract Amount ________________ When Completed ________________________ Type of Project _______________________________________________________ Location of Project _________________________________________________ Name, Address & Phone Number of Owner _____________________________________________________ 5. Contract Amount ___________________ When Completed _____________________ Type of Project _____________________________________________________ Location of Project _________________________________________________ Name, Address & Phone Number of Owner _________________________________________________ SECTION V I. & VII. Page 25 rev 11/21/13 List all experience for the past five years in the following categories for which you want to qualify. VI. What Sewer or Building projects is your organization now in process of constructing? 1. Contract Amount ____________ Scheduled Completion Date _______________ Type of Project ___________________________________________________ Location of Project _______________________________________________ Name, Address & Phone Number of Owner __________________________________________________ 2. Contract Amount ________________ Scheduled Completion Date ____________ Type of Project ____________________________________________________ Location of Project __________________________________________________ Name, Address & Phone Number of Owner _________________________________________________ 3. Contract Amount ____________ Scheduled Completion Date _______________ Type of Project ___________________________________________________ Location of Project _______________________________________________ Name, Address & Phone Number of Owner __________________________________________________ 4. Contract Amount ________________ Scheduled Completion Date ____________ Type of Project ____________________________________________________ Location of Project _________________________________________________ Name, Address & Phone Number of Owner _________________________________________________ NOTE: If more space is needed, attach additional sheets. VII. Have you ever failed to complete any work awarded to you? (If so, explain) ____________________________________________________________________ SECTION - Equipment Page 26 rev 11/21/13 EQUIPMENT (What equipment do you own that is available for proposed work?) QUANTITY ITEM DESCRIPTION, SIZE, CAPACITY, ETC EQUIP HOURS CONDITION YEARS OF SERVICE PRESENT LOCATION * Condition shall be graded as follows: New under 12 months Over 12 months old Rebuilt N-1 0-1 (Good) R-1 0-2 (Average) R-2 0-3 (Fair) R-3 0-4 (Poor) R-4 (Poor) Page 27 AFFIDAVIT FOR INDIVIDUAL State of ____________________) ) ss. County of __________________ ) ___________________________________________, being duly sworn, deposes and says that the answers to the foregoing interrogatories are true, and that any depository, vendor or other agency herein named is authorized to supply The Metropolitan St. Louis Sewer District with any information necessary to verify this statement. __________________________________ (Applicant sign here) Sworn to before me, this _______________ day of ____________________, 20 _____. _____________________________ Notary Public (seal) AFFIDAVIT FOR CO-PARTNERSHIP State of _____________________) ) ss. County of ___________________) ___________________________________, being duly sworn, deposes and says that they are a member of the firm of ___________________________________ that they are familiar with the books of said firm showing its financial condition; and that the answers to the foregoing interrogatories are true, and that any depository, vendor or other agency herein named is authorized to supply The Met ropolitan St. Louis Sewer District with any information necessary to verify this statement. ________________________________ _________________________________ ________________________________ (Members of firm, sign above) Sworn to before me, this _______________ day of ____________________, 20____. _____________________________ Notary Public (seal) AFFIDAVIT FOR CORPORATION State of ______________________) ) ss. County of ____________________ ) ________________________________, being duly sworn, deposes and says that ___he is ___________________________________________________________of the _______________________________________________________________________ the corporation described in and which executed the foregoing statement that ____he is familiar with the books of the said corporation, showing its financial condition; and that the answers of the foregoing interrogatories are true, and that any depository, vendor or other agency herein named is authorized to supply The Metropolitan St. Louis Sewer District with any information necessary to verify this statement. ________________________________ ________________________________ Title _______________________________ _______________________________ Title Sworn to before me, this _______________ day of __________________, 20 _______. _______________________________ Notary Public (seal)